Forms

Many of the following forms are interactive PDF forms. Please type or print legibly the information into them, print, and obtain signatures.

Forms may be sent via mail, by fax, or scanned and sent via email. Please maintain originals for your files.

MMEHT
60 Community Drive
Augusta, ME 04330
FAX: (207) 624-0166
E-mail: htbilling@memun.org

 

Billing Information and Enrollment Forms:

• Medical Enrollment/Change Form
• Dental Enrollment/Change Form
• Income Protection Plan Enrollment Form
• Vision Enrollment/Change Form
• Life Enrollment/ Change Form
• Domestic Partner Affidavit
• Employer Contributions Reporting Form 
  (This completed form must be returned along with your Remittance Form and monthly payment.)

Change Forms:

• Salary Change Form (Excel)
• Termination Notification Form
• Retiree Eligibility Form
• Change of Address Form

Claim Forms:

• Dental Claim Form
• Health Claim Form
• Prescription Claim Form
• Income Protection Plan (IPP) Claim Form (for Short Term Disability)
• International Claim Form (BlueCard Worldwide)
• Long Term Disability (LTD)
• VSP Vision Out-of-Network Reimbursement Form

HIPAA Forms

• HIPAA Authorization Form

To obtain Plan Summaries, please refer to the page for the appropriate benefits program.